Do selective serotonin reuptake inhibitors cause suicide?

Editor—The decline in routine prescribing of antidepressants in children and adolescents expected by Cipriani et al has already started.¹ We analysed antidepressant prescribing by general practitioners between 1 January 2000 and 31 December 2004 using the IMS Disease Analyzer-Mediplus database to examine the effects of the UK Committee on Safety of Medicines' advice on antidepressant prevalence.²,³

Antidepressant use increased between 2000 and 2002 (5.4 per 1000 to 6.6/1000); the prescription of selective serotonin reuptake inhibitors (SSRIs) and venlafaxine rose. Between 2002 and 2004 antidepressant prevalence decreased (6.6/1000 to 5.7/1000). The use of the withdrawn antidepressants (citalopram, escitalopram, fluvoxamine, paroxetine, sertraline, and venlafaxine) dropped by a third (3.1/1000 v 2.0/1000), but there was no change in fluoxetine prevalence (2.1/1000 v 2.3/1000). The use of tricyclic antidepressants declined (2.0/1000 v 1.7/1000; P = 0.03).

Since 2003 fewer children and adolescents have been prescribed antidepressants in primary care, particularly the withdrawn drugs. However, the use of fluoxetine and non-selective SSRIs has not risen, implying that they are not used as alternative treatments.

Fewer prescriptions may be issued for mild depression, or patients and their parents are more aware, and therefore more cautious, about antidepressant treatment. Also, clinicians may choose psychotherapies, such as cognitive behaviour therapy, over antidepressants.

New referrals to child and adolescent mental health services need to be measured for health service planning. Further research into the integrated management of depression in childhood and adolescence is urgently required so that adequate infrastructure and resources can be provided.